Pursuing living donor liver transplantation improves outcomes of patients with autoimmune liver diseases - An intention-to-treat analysis.

Background Living donor liver transplantation (LDLT) offers the opportunity to decrease waitlist time and mortality for patients with AILD; autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), and primary sclerosing cholangitis (PSC). We compared the survival of patients with a potential live donor (pLDLT) on the waitlist vs. no potential live donor (pDDLT), on an intention-to-treat (ITT) basis. Methods Our retrospective cohort study investigated adults with AILD listed for liver transplant at our program between 2000 and 2021. The pLDLT group comprised recipients with a potential live donor. Otherwise, they were included in the pDDLT group. ITT survival was assessed from the time of listing. Results Of the 533 patients included, 244(43.8%) had a potential living donor. Waitlist dropout was higher for the pDDLT groups among all AILDs (pDDLT 85[29.4%] vs. pLDLT 9[3.7], p<0.001). The 1-, 3- and 5-year ITT survival rates were higher for pLDLT vs. pDDLT among all AILDs (95.7%vs.78.1%, 89.0%vs.70.1%, and 87.1%vs.65.5%, p<0.001). After adjusting for covariates, pLDLT was associated with a 38% reduction in the risk of death among the AILD cohort (HR:0.62, 95%CI:0.42-0.93[p<0.05]), and 60% among the PSC cohort (HR:0.40, 95%CI:0.22-0.74[p<0.05]). There were no differences in the 1-, 3- and 5-year post-transplant survival between LDLT and DDLT (AILD: 95.6%vs.92.1%, 89.9%vs.89.4%, and 89.1%vs. 87.1%, p=0.41). This was consistent after adjusting for covariates (HR: 0.97, 95%CI:0.56-1.68[p>0.9]). Conclusion Our study suggests that having a potential live donor could decrease the risk of death in patients with PSC on the waitlist. Importantly, the post-transplant outcomes in this population are similar between the LDLT and DDLT groups.

Call to Improve the Quality of Prediction Tools for Intrahepatic Cholangiocarcinoma Resection: A Critical Appraisal, Systematic Review, and External Validation Study.

Objective: To conduct a systematic review, critical appraisal, and external validation of survival prediction tools for patients undergoing intrahepatic cholangiocarcinoma (iCCA) resection. Summary background data: Despite the development of several survival prediction tools in recent years for patients undergoing iCCA resections, there is a lack of critical appraisal and external validation of these models. Methods: We conducted a systematic review and critical appraisal of survival and recurrence prediction models for patients undergoing curative-intent iCCA resections. Studies were evaluated based on their model design, risk of bias, reporting, performance, and validation results. We identified the best model and externally validated it using our institution's data. Results: This review included a total of 31 studies, consisting of 26 studies with original prediction tools and 5 studies that only conducted external validations. Among the 26, 54% of the studies conducted internal validations, 46% conducted external validations, and only 1 study scored a low risk of bias. Harrell's C-statistics ranged from 0.67 to 0.76 for internal validation and from 0.64 to 0.75 for external validation. Only 81% of the studies reported model calibration. Our external validation of the best model (Intrahepatic Cholangiocarcinoma [ICC]-Metroticket) estimated Harrell's and Uno's C-statistics of 0.67 (95% CI: 0.56-0.77) and Uno's time-dependent area under the receiver operating characteristic curve (AUC) of 0.71 (95% CI: 0.53-0.88), with a Brier score of 0.20 (95% CI: 0.15-0.26) and good calibration plots. Conclusions: Many prediction models have been published in recent years, but their quality remains poor, and minimal methodological quality improvement has been observed. The ICC-Metroticket was selected as the best model (Uno's time-dependent AUC of 0.71) for 5-year overall survival prediction in patients undergoing curative-intent iCCA resection.

Mapping a shared care model in complex gastrointestinal surgery: A qualitative study of queues and stakeholders within a Canadian general surgery practice.

Shared Care Models (SCMs), in which a team of clinicians share in patient care and resource utilization, represent an opportunity for surgeon-level system change. We aimed to identify the queues and stakeholders within a complex gastrointestinal surgical care pathway to demonstrate the implications of a SCM on system efficiency. A multidisciplinary group of surgeons and care navigators working in SCMs were asked to develop a patient encounter map through consensus to illustrate relevant queues and stakeholders within a SCM. Fifteen surgeon-related queues were identified, each representing a point of potential delay to care in the patient's journey that could be addressed by shared care. A final patient encounter map was created, and advantages and challenges of SCMs were also described from multidisciplinary group discussions. The numerous queues identified in this map ultimately reflected opportunities for more efficient care navigation under a SCM through increased surgeon availability and shared resource utilization.

Role of intraoperative processes of care during major upper gastrointestinal oncological resection in postoperative outcomes: a scoping review protocol.

INTRODUCTION: Optimal delivery and organisation of care is critical for surgical outcomes and healthcare systems efficiency. Anaesthesia volumes have been recently associated with improved postoperative recovery outcomes; however, the mechanism is unclear. Understanding the individual processes of care (interventions received by the patient) is important to design effective systems that leverage the volume-outcome association to improve patient care. The primary objective of this scoping review is to systematically map the evidence regarding intraoperative processes of care for upper gastrointestinal cancer surgery. We aim to synthesise the quantity, type, and scope of studies on intraoperative processes of care in adults who undergo major upper gastrointestinal cancer surgeries (oesophagectomy, hepatectomy, pancreaticoduodenectomy, and gastrectomy) to better understand the volume-outcome relationship for anaesthesiology care. METHODS AND ANALYSIS: This scoping review will follow the Arksey and O'Malley framework and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension framework for scoping reviews. We will systematically search MEDLINE, Embase and Cochrane databases for original research articles published after 2010 examining postoperative outcomes in adult patients undergoing either: oesophagectomy, hepatectomy, pancreaticoduodenectomy, or gastrectomy, which report at least one intraoperative processes of care (intervention or framework) applied by anaesthesia or surgery. The data from included studies will be extracted, charted, and summarised both quantitatively and qualitatively through descriptive statistics and narrative synthesis. ETHICS AND DISSEMINATION: No ethics approval is required for this scoping review. Results will be disseminated through publication targeted at relevant stakeholders in anaesthesiology and cancer surgery. TRIAL REGISTRATION NUMBER: 10.17605/OSF.IO/392UG; https://archive.org/details/osf-registrations-392ug-v1.

Toronto Management of Initially Unresectable Liver Metastasis from Colorectal Cancer in a Living Donor Liver Transplant Program.

BACKGROUND: Living donor liver transplantation (LDLT) is an attractive option for patients with unresectable, bilobar colorectal liver metastases (CRLM). However, it is not available in most centers beyond study protocols. This study describes the interim experience with LDLT for CRLM at a large North American transplant and hepatobiliary center. f. STUDY DESIGN: Adults with unresectable CRLM, receiving systemic chemotherapy, were recruited into a prospective clinical trial. Data on demographics, referral patterns, and clinical characteristics were extracted from October 2016 to February 2023. Patients were divided into 3 groups: transplanted, resected, and control (excluded with continuation of systemic chemotherapy). Overall survival and recurrence-free survival were compared. RESULTS: Eighty-one referred patients were assessed for LDLT: 7 received transplants, 22 underwent resection, and 48 were controls. All had similar preassessment baseline characteristics. Median time from initial assessment to transplantation was 15.4 months. The control population had significantly worse postassessment overall survival than the transplanted population (p = 0.002) and resected population (p < 0.001). The median postoperative follow-up duration was 21.4 months (resection) and 14.8 months (LDLT). There was no difference in overall survival between the transplanted and resected populations (1-year 100% vs 93.8%; 3-year 100% vs 43.3%, p = 0.17). However, recurrence-free survival was superior in the LDLT group (1-year 85.7% vs 11.4%; 3-year 68.6% vs 11.4%, p = 0.012). CONCLUSIONS: Most patients with unresectable CRLM referred for LDLT are deemed ineligible for trial inclusion. However, the excellent oncologic outcomes in patients who meet criteria for LDLT supports its role in highly selected populations. Future results after the trial's completion will inform long-term outcomes.

Lymphopenia at the time of transplant is associated with short-term mortality after deceased donor liver transplantation.

Absolute lymphocyte count (ALC) is considered a surrogate marker for nutritional status and immunocompetence. We investigated the association between ALC and post-liver transplant outcomes in patients who received a deceased donor liver transplant (DDLT). Patients were categorized by ALC at liver transplant: low (<500/µL), mid (500-1000/µL), and high ALC (>1000/µL). Our main analysis used retrospective data (2013-2018) for DDLT recipients from Henry Ford Hospital (United States); the results were further validated using data from the Toronto General Hospital (Canada). Among 449 DDLT recipients, the low ALC group demonstrated higher 180-day mortality than mid and high ALC groups (83.1% vs 95.8% and 97.4%, respectively; low vs mid: P = .001; low vs high: P < .001). A larger proportion of patients with low ALC died of sepsis compared with the combined mid/high groups (9.1% vs 0.8%; P < .001). In multivariable analysis, pretransplant ALC was associated with 180-day mortality (hazard ratio, 0.20; P = .004). Patients with low ALC had higher rates of bacteremia (22.7% vs 8.1%; P < .001) and cytomegaloviremia (15.2% vs 6.8%; P = .03) than patients with mid/high ALC. Low ALC pretransplant through postoperative day 30 was associated with 180-day mortality among patients who received rabbit antithymocyte globulin induction (P = .001). Pretransplant lymphopenia is associated with short-term mortality and a higher incidence of posttransplant infections in DDLT patients.

Outcomes of liver transplantation in non-alcoholic steatohepatitis (NASH) versus non-NASH associated hepatocellular carcinoma.

BACKGROUND: Non-alcoholic steatohepatitis (NASH)-associated hepatocellular carcinoma (HCC) is a rising indication for liver transplantation. This unique population, with multiple comorbidities, has potential for worse post-transplant outcomes. We compared post-transplant survival of NASH and non-NASH HCC patients using a large cohort. METHODS: Adults transplanted for HCC between 2008 and 2018, from United Network for Organ Sharing (UNOS) and University Health Network (UHN) databases were divided into two populations: NASH and non-NASH. Recipient characteristics and post-transplant survival were compared. Subgroup analyses were performed within and beyond Milan criteria. RESULTS: 2071 of 20,672 (10.0%) patients underwent transplantation for NASH HCC, with annual proportional increase of 1.2%UHN (p = 0.02) and 1.3%UNOS (p < 0.001). The 1-,3-,5-year post-transplant survival were 90.8%, 83.9%, 76.3% NASH HCC versus 91.9%, 82.1%, 74.9% non-NASH HCC (p = 0.94). No survival differences were observed in populations within or beyond Milan. Competing-risk analysis demonstrated no differences in risk for cardiovascular-related death (HR1.24, 95%CI 0.87-1.55, p = 0.16), or HCC recurrence-related death (HR1.21, 95%CI 0.89-1.65, p = 0.23). NASH HCC patients had lower risk of liver-related deaths (HR0.57, 95%CI 0.34-0.98, p = 0.04). DISCUSSION: NASH HCC is a rising indication for liver transplantation. Despite demographic differences, no post-transplantation survival differences were observed between NASH and non-NASH HCC. This justifies equivalent organ allocation, irrespective of NASH status.

Feasibility and Safety of a "Shared Care" Model in Complex Hepatopancreatobiliary Surgery: A 5-year Observational Study of Outcomes in Pancreaticoduodenectomy.

OBJECTIVE: To determine the safety of a fully functioning shared care model (SCM) in hepatopancreatobiliary surgery through evaluating outcomes in pancreaticoduodenectomy. BACKGROUND: SCMs, where a team of surgeons share in care delivery and resource utilization, represent a surgeon-level opportunity to improve system efficiency and peer support, but concerns around clinical safety remain, especially in complex elective surgery. METHODS: Patients who underwent pancreaticoduodenectomy between 2016 and 2020 were included. Adoption of shared care was demonstrated by analyzing shared care measures, including the number of surgeons encountered by patients during their care cycle, the proportion of patients with different consenting versus primary operating surgeon (POS), and the proportion of patients who met their POS on the day of surgery. Outcomes, including 30-day mortality, readmission, unplanned reoperation, sepsis, and length of stay, were collected from the institution's National Surgical Quality Improvement Program (NSQIP) database and compared with peer hospitals contributing to the pancreatectomy-specific NSQIP collaborative. RESULTS: Of the 174 patients included, a median of 3 surgeons was involved throughout the patients' care cycle, 69.0% of patients had different consenting versus POS and 57.5% met their POS on the day of surgery. Major outcomes, including mortality (1.1%), sepsis (5.2%), and reoperation (7.5%), were comparable between the study group and NSQIP peer hospitals. Length of stay (10 day) was higher in place of lower readmission (13.2%) in the study group compared with peer hospitals. CONCLUSIONS: SCMs are feasible in complex elective surgery without compromising patient outcomes, and wider adoption may be encouraged.

Association of Viral Hepatitis Status and Post-hepatectomy Outcomes in the Era of Direct-Acting Antivirals.

BACKGROUND: The role of viral hepatitis status in post-hepatectomy outcomes has yet to be delineated. This large, multicentred contemporary study aimed to evaluate the effect of viral hepatitis status on 30-day post-hepatectomy complications in patients treated for hepatocellular carcinoma (HCC). METHODS: Patients from the National Surgical Quality Improvement Program (NSQIP) database with known viral hepatitis status, who underwent hepatectomy for HCC between 2014 and 2018, were included. Patients were classified as HBV-only, HCV-only, HBV and HCV co-infection (HBV/HCV), or no viral hepatitis (NV). Multivariable models were used to assess outcomes of interest. The primary outcome was any 30-day post-hepatectomy complication. The secondary outcomes were major complications and post-hepatectomy liver failure (PHLF). Subgroup analyses were performed for cirrhotic and noncirrhotic patients. RESULTS: A total of 3234 patients were included. The 30-day complication rate was 207/663 (31.2%) HBV, 356/1077 (33.1%) HCV, 29/81 (35.8%) HBV/HCV, and 534/1413 (37.8%) NV (p = 0.01). On adjusted analysis, viral hepatitis status was not associated with occurrence of any 30-day post-hepatectomy complications (ref: NV, HBV odds ratio (OR) 0.89 [95% confidence interval (CI): 0.71-1.12]; HCV OR 0.91 [95% CI: 0.75-1.10]; HBV/HCV OR 1.17 [95% CI: 0.71-1.93]). Similar results were found in cirrhotic and noncirrhotic subgroups, and for secondary outcomes: occurrence of any major complications and PHLF. CONCLUSIONS: In patients with HCC managed with resection, viral hepatitis status is not associated with 30-day post-hepatectomy complications, major complications, or PHLF compared with NV. This suggests that clinical decisions and prognostication of 30-day outcomes in this population likely should not be made based on viral hepatitis status.

Long-term outcomes of retransplantation after live donor liver transplantation: A Western experience.

BACKGROUND: Despite most liver transplants in North America being from deceased donors, the number of living donor liver transplants has increased over the last decade. Although outcomes of liver retransplantation after deceased donor liver transplantation have been widely published, outcomes of retransplant after living donor liver transplant need to be further elucidated. METHOD: We aimed to compare waitlist outcomes and survival post-retransplant in recipients of initial living or deceased donor grafts. Adult liver recipients relisted at University Health Network between April 2000 and October 2020 were retrospectively identified and grouped according to their initial graft: living donor liver transplants or deceased donor liver transplant. A competing risk multivariable model evaluated the association between graft type at first transplant and outcomes after relisting. Survival after retransplant waitlisting (intention-to-treat) and after retransplant (per protocol) were also assessed. Multivariable Cox regression evaluated the effect of initial graft type on survival after retransplant. RESULTS: A total of 201 recipients were relisted (living donor liver transplants, n = 67; donor liver transplants, n = 134) and 114 underwent retransplant (living donor liver transplants, n = 48; deceased donor liver transplants, n = 66). The waitlist mortality with an initial living donor liver transplant was not significantly different (hazard ratio = 0.51; 95% confidence interval, 0.23-1.10; P = .08). Both unadjusted and adjusted graft loss risks were similar post-retransplant. The risk-adjusted overall intention-to-treat survival after relisting (hazard ratio = 0.76; 95% confidence interval, 0.44-1.32; P = .30) and per protocol survival after retransplant (hazard ratio:1.51; 95% confidence interval, 0.54-4.19; P = .40) were equivalent in those who initially received a living donor liver transplant. CONCLUSION: Patients requiring relisting and retransplant after either living donor liver transplants or deceased donor liver transplantation experience similar waitlist and survival outcomes.

Should Cell Salvage Be Used in Liver Resection and Transplantation? A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate the effect of intraoperative blood cell salvage and autotransfusion (IBSA) use on red blood cell (RBC) transfusion and postoperative outcomes in liver surgery. BACKGROUND: Intraoperative RBC transfusions are common in liver surgery and associated with increased morbidity. IBSA can be utilized to minimize allogeneic transfusion. A theoretical risk of cancer dissemination has limited IBSA adoption in oncologic surgery. METHODS: Electronic databases were searched from inception until May 2021. All studies comparing IBSA use with control in liver surgery were included. Screening, data extraction, and risk of bias assessment were conducted independently, in duplicate. The primary outcome was intraoperative allogeneic RBC transfusion (proportion of patients and volume of blood transfused). Core secondary outcomes included: overall survival and disease-free survival, transfusion-related complications, length of hospital stay, and hospitalization costs. Data from transplant and resection studies were analyzed separately. Random effects models were used for meta-analysis. RESULTS: Twenty-one observational studies were included (16 transplant, 5 resection, n=3433 patients). Seventeen studies incorporated oncologic indications. In transplant, IBSA was associated with decreased allogeneic RBC transfusion [mean difference -1.81, 95% confidence interval (-3.22, -0.40), P =0.01, I 2 =86%, very-low certainty]. Few resection studies reported on transfusion for meta-analysis. No significant difference existed in overall survival or disease-free survival in liver transplant [hazard ratio (HR)=1.12 (0.75, 1.68), P =0.59, I 2 =0%; HR=0.93 (0.57, 1.48), P =0.75, I 2 =0%] and liver resection [HR=0.69 (0.45, 1.05), P =0.08, I 2 =0%; HR=0.93 (0.59, 1.45), P =0.74, I 2 =0%]. CONCLUSION: IBSA may reduce intraoperative allogeneic RBC transfusion without compromising oncologic outcomes. The current evidence base is limited in size and quality, and high-quality randomized controlled trials are needed.

Evaluating the Accuracy and Design of Visual Abstracts in Academic Surgical Journals.

OBJECTIVE: The objective of this study was to assess the quality and accuracy of visual abstracts published in academic surgical journals. BACKGROUND: Visual abstracts are commonly used to disseminate medical research findings. They distill the key messages of a research article, presenting them graphically in an engaging manner so that potential readers can decide whether to read the complete manuscript. METHODS: We developed the Visual Abstract Assessment Tool based upon published guidelines. Seven reviewers underwent iterative training to apply the tool. We collected visual abstracts published by 25 surgical journals from January 2017 to April 2021; those corresponding to systematic reviews without meta-analysis, conference abstracts, narrative reviews, video abstracts, or nonclinical research were excluded. Included visual abstracts were scored on accuracy (as compared with written abstracts) and design, and were given a "first impression" score. RESULTS: Across 25 surgical journals 1325 visual abstracts were scored. We found accuracy deficits in the reporting of study design (35.8%), appropriate icon use (49%), and sample size reporting (69.2%), and design deficits in element alignment (54.8%) and symmetry (36.1%). Overall scores ranged from 9 to 14 (out of 15), accuracy scores from 4 to 8 (out of 8), and design scores from 3 to 7 (out of 7). No predictors of visual abstract score were identified. CONCLUSION: Visual abstracts vary widely in quality. As visual abstracts become integrated with the traditional components of scientific publication, they must be held to similarly high standards. We propose a checklist to be used by authors and journals to standardize the quality of visual abstracts.

Patient-centered outcomes for gastrointestinal cancer care: a scoping review protocol.

INTRODUCTION: Following a cancer diagnosis, patients and their caregivers face crucial decisions regarding goals of care and treatment, which have consequences that can persist throughout their cancer journey. To foster informed and value-driven treatment choices, evidence-based information on outcomes relevant to patients is needed. Traditionally, clinical studies have largely focused on a few concrete and easily measurable outcomes such as survival, disease progression and immediate treatment toxicities. These outcomes do not capture other important factors that patients consider when making treatment decisions. Patient-centred outcomes (PCOs) reflect the patients' individual values, preferences, needs and circumstances that are essential to directing meaningful and informed healthcare discussions. Often, however, these outcomes are not included in research protocols in a standardised and practical fashion. This scoping review will summarise the existing literature on PCOs in gastrointestinal (GI) cancer care as well as the tools used to assess these outcomes. A comprehensive list of these PCOs will be generated for future efforts to develop a core outcome set. METHODS AND ANALYSIS: This scoping review will follow Arksey and O'Malley's expanded framework for scoping reviews. We will systematically search Medline, Embase, CINAHL, Cochrane Library and APA PsycINFO databases for studies examining PCOs in the context of GI cancer. We will include studies published in or after the year 2000 up to the date of the final searches, with no language restrictions. Studies involving adult patients with GI cancers and discussion of any PCOs will be included. Opinion pieces, protocols, case reports and abstracts will be excluded. Two authors will independently perform two rounds of screening to select studies for inclusion. The data from full texts will be extracted, charted and summarised both quantitatively and qualitatively. ETHICS AND DISSEMINATION: No ethics approval is required for this scoping review. Results will be disseminated through scientific publication and presentation at relevant conferences.

Junior Mentorship Program (JuMP) Start in Surgery-Implications on Trainee Success.

BACKGROUND: Surgical residency, and particularly the early transition years into junior residency or internship, poses great challenges to the trainee, with implications on success, burnout, and attrition. There is increasing recognition of the benefits of mentorship in surgery, however, significant barriers exist in forming these relationships. Peer mentorship also has many additional benefits, though its role in surgical training is limited. The objective of this study was to evaluate the experience following implementation of a formalized peer mentorship program within a large surgical training program. METHODS: Fourteen post-graduate year 1 (PGY1) general surgery residents were each interviewed and voluntarily matched with a post-graduate year 2 (PGY2) general surgery resident at the University of Toronto for the July 2019 to June 2020 academic year. The recommendation was for an initial meet-and-greet, followed by meetings once every 1 to 2 months. Meetings and discussion topics were encouraged, including emphasis on wellness, study skills, team leadership, and an opportunity to share experiences or concerns. A 1-year post-implementation survey was sent out individually to both groups. RESULTS: Twenty-eight general surgery residents were surveyed (14 PGY1s, 14 PGY2s). Seventy percent (11/14) of PGY1s responded, while 50% (7/14) PGY2s responded. Three themes emerged from survey: I) peer mentorship provides multiple benefits, II) similar personalities make for a good peer mentorship pair, III) formal scheduled sessions for mentorship should be implemented into the residency curriculum. CONCLUSIONS: Amongst junior general surgery residents, a formal peer mentorship program provides benefits to both the mentor and mentee. Scheduling difficulties in the absence of structured meetings, and the importance of the mentee-mentor match are key considerations for successful implementation of a mentorship program. Further longitudinal and multicentre studies can be performed to evaluate the long-term impact of these formalized peer mentorship programs on surgical trainee success, including burnout and attrition.